Ethics of politics in health care

The last few months, since the leave of Health Secretary Enrique Ona from the Department of Health, the health department has received several flaks from certain parties with vested interest and conflicts of interest on the matter.

I do not personally know the health secretary. However, the allegations being thrown at him, from no less than the President of the Republic of the Philippines himself has left me wondering why there is so much ire against him by no less than the person who appointed him to that position?

So far, the president has defended all his appointees, especially the favored ones. From PNP Chief Purisima who has been accused of falsifying his SALNs to Sec. Butch Abad who has been shaving the PDAF in favor of the DAP to DOTC Secretary Abaya who has been accused of running the MRT projects and bids as a family affair...strangely, it is the health secretary who has been in the news lately on controversies after controversies.

While I may not agree at certain issues with the health secretary, there are, however, public health issues that are valid decisions made on behalf of the public.


Vaccines and Public Health

Is the PCV 13 really superior to PCV 10?

There has never been a published study on a head-to-head long term study on the efficacy of preventing pneumonia, otitis media and invasive pneumococcal disease between the two vaccines.

The pneumococcal conjugate vaccine is designed to protect against the serotypes in the vaccine. For example, PCV 10 should cover against the 10 serotypes with additional cross protection against one or two other serotypes. PCV 13 should cover against 13 serotypes. Both vaccines DO NOT guarantee 100% efficacy. Improved vaccine efficacy end-points are based on the completion of all doses administered and NOT JUST ONE DOSE.

The Philippine Daily Inquirer reported that Dr. Issa Alejandria, an infectious disease specialist and epidemiologist at the UP-PGH said that PCV 13 averted more cases of pneumonia, otitis media, and invasive pneumococcal disease during a health forum in Quezon City. I am not sure whether the reporters just got confused or that the message Dr. Alejandria delivered may not have been completely accurate. But let me get that clear. There is NO WAY you can tell exactly how many cases of pneumococcal illness was averted by providing either of the vaccines. The data can only provide a mathematical approximation of "what ifs" based on the serotypes that are covered by each of the vaccine.

Clearly, there are issues that were blown out of proportion.

First. Did the World Health Organization actually file a complaint on which vaccine was to be used? NO. The utilization of which vaccine to recommend lies on each agency and each country based on local epidemiology. Both vaccines are WHO Prequalified.


Second. If you look at the vaccines being given at the health centers, or even by the Department of Health, many, are actually different from what is being given in private clinics. The DTwP or whole cell pertussis version is still being given in the community setting in spite of the fact that it is noted to be more reactogenic (higher side effects). Why? Not because it is not better. Studies now show that the wP version may actually be more effective (although more reactogenic), but a lot cheaper than the DTaP or acellular pertussis version.

As a concrete example, in selected areas where the rotavirus vaccine is being given for free, the monovalent rotavirus vaccine is the one that is being administered in spite of the fact that it covers only the G1P8 strains. Local epidemiological data from studies out of the Research Institute for Tropical Medicine have shown that the circulating strains may vary from year to year. For the Philippines, more than 70% of the circulating strains in the past three years have been G2 and G3 with less than 10% attributable to G1P8. Why was a monovalent vaccine selected over a pentavalent vaccine when the latter is also available in the Philippines? Because of cost issues.

And I can go on and on about the vaccines available in from the government compared to the ones being administered in the clinics, but this is beyond the scope of my blog.

Public health programs are designed to address a more comprehensive health coverage in spite of limited financial resources. The decision to use either the PCV 10 or 13 should be based on economics. Given the fact that there are more than 15 Million children less than 5 years old in this country, the 560,000 doses of the PCV 10 that was bought (vs. 520,000 doses if PCV 13 was purchased) was not even enough to AVERT anything. Each child will need 4 doses of the vaccine. Which means that with PCV 10, only 140,000 children would receive full immunization (or 130,000 children had PCV 13 been used). 10,000 children receiving PCV vaccine is much higher than the mathematically derived "averted" numbers.

A study published in Vaccine [Vol 30 Issue 11 on March 2, 2012, pp. 1936-1943] by Castañeda-Orjuela et. al. showed that using a Markov model, the authors evaluated the cost-effectiveness of three PCV vaccines - 7, 10 and 13. While PCV 13 may have increased the expectancy of LGY (life-gained years), the ICERs (Incremental cost-effectiveness ratios) of PCV 13 was above the per capita Gross Domestic Product. The study concluded that while PCV 13 would prevent more diseases and deaths with higher LGY, PCV 10 would save more cost to the healthcare system due to its higher impact in the prevention of Acute Otitis Media.

In the Philippines alone, data from the RITM on the Antimicrobial Resistance Surveillance Program in 2013 showed that of the 25 isolates for invasive pneumococcal disease, the most common were serotypes 1 and 5. The other serotypes reported were: 2, 14, 23, 18, 3, 4, 6, 19, 20, 32, 33, and 34.

PCV 10 covers against serotypes 1, 4, 5, 6B, 7F, 9V, 14, 18C, 19F and 23F.
PCV 13 covers against serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F.

Both vaccines did not cover against serotypes 20, 32, 33, and 34.

The only reported case of serotype 3 in 2013 was in an adult patient in the 20-64 years old bracket.


Which goes to the third point. The immunization program of the government covers only children and DOES NOT include adults.

As to what the president was ranting and panting in his press statements regarding this issue, smells of politics reeling its ugly head.



Cure for Dengue

I had patients that were asking me about the latest "cure" for dengue. This is the drug called ActRX TRIACT being marketed by the son of former senator Heherson Alvarez. The drug, a mixture of artemisinin-artesunate-berberin is claimed to be a breakthrough drug developed supposedly by ActRX Operational Group. Ltd. with its office out of Clark Freeport Zone, Pampanga.

As a pharmacologist, I have to put my foot down on this issue. I do not know why this clinical trial was even given a green light by the DOH. In the first place, artemisinin-artesunate are one of the most effective first line drugs in the treatment of P. falciparum malaria. Making it available for "dengue" is dangerous because the Philippines is endemic for malaria as well. Inadvertent use for every clinical symptom that smells like or looks like "dengue" can be catastrophic at the global control of malaria.

We need to remember that one has a cure (malaria), the other DOES NOT (dengue). Dengue is a self-limited disease and like many viruses, the key to addressing the problem is looking for the right vaccine. In addition, appropriate maintenance of a cleaner environment will address the outbreaks we see. Unfortunately, the present environmental and living conditions of the Filipinos will always remain a problem unless government steps in to alleviate the plight of the poorer sectors of society.

The premature approval and the marketing claims of the company that sells this is unfounded and unethical. It is but right that the clinical trials be stopped until more evidence can be shown that the use of the antimalarial drug artemisinin-artesunate has a role in the treatment of Dengue.


When someone asked me what my thoughts were of the current storm the health department is facing, I simply said that it was political.

I don't know what other baggage the administration will throw Ona's way, but please spare the public. All this political mileage is pushing the health of the public into limbo.

The worst kind of politics is to involve the continued delivery of health care to the people. What you see now is similar to PNoy approving the conduct of a badly designed clinical trial, short of calling it unethical, only because there is a pawn that can be played and that outcomes are only for the good of political alliances. Never mind the health care of the public. After all, for the longest time, the annual health budget is one of the lowest in the world. And the people do not consider health as a priority.

Noted author Laurie Garrett puts it best in perspective when she says "What public health really is is a trust. That's why I used the term 'Betrayal of Trust' as the title of my book. It's a trust between the government and the people".

Three

I did not get the chance to say goodbye.

On September 16, 2014, I formally stepped aside from being Chair of the Department of Pediatrics at Asian Hospital and Medical Center, a position I accepted three years ago.

In 2011, when I assumed the position to lead a department at the hospital, my initial reaction was fear. I don't know how many of my colleagues knew that, but now I can confess to you my skepticism in accepting the role. I was afraid. Because I barely knew 30% of you. Because I did not know how you would accept me. Because I did not want to let you down on expectations.

The first few nights were practically sleepless ones for me. I would call or drag Bettina to one side and ask her who all the pediatricians at the hospital were. We would go through your names one by one and I would need to place a face in the name. While many of you knew me because you either were once my students or had heard me give a lecture in some conference or convention, I needed to get to know you better. I would ponder and dream of great things for our department. After all, pediatrics is not a major contributor to the financial coffers with "toys for the big boys" like surgery or "dramatic landscapes and stories" like oncology or "sculpting and laser technologies for the forever young" like dermatology. You get kids - either sick or the newborn. They come in for a couple of days. We fix their disease. They go home. No fanfare there.

Where do we put our mark in this hospital?

Three years ago seemed such a long time. On our first staff meeting, I laid out my plans and asked your support. I believe you were all overwhelmed.

Residency training.

Mother-baby friendly hospital.

Pediatrics office.

Continuing medical education courses.


Was I dreaming or was I crazy? Is he nuts? Did we just elect the wrong person to lead us? My God we're going to actually work?!?!

I needed to prove to you that together, no dream would be too small to achieve.

The three years went by very quickly.

Somewhere along the road, someone decided that JCI Accreditation would be part of the picture. That wasn't in our road map initially. But together, we took it in stride. Even if I had to stand at the podium for the next 9 straight hours giving the lecture, by golly I did and my God, you all stayed behind to finish it!

We had our official accreditations for life support programs and when push came to shove, the remaining few that were not board certified really proved to themselves (and to me), that, yes, they could do it. Taking the amnesty certification exam was no small task and I take my hats off to all who took it and congratulate those who made it. It was a pat on your back that you truly deserved. I just provided the push, but you made yourselves proud.

The back-to-back annual continuing medical education activities were tremendously successful. We raised enough funds to contribute to the continuing education and training of our own residents as well.

The mother-baby-friendly hospital was a challenge because it would mean the cooperation of the department of Obstetrics and the hospital administration. We had a few disappointments from moms posting on FB their rules of engagement for being breastfeeding advocates, but we stuck our guns and still bagged being accredited MBFH and being the only hospital that's accredited being mother-baby friendly in the workplace too!!!

And of course my pet project, the pediatric residency program. During our first try at it, we were gently struck down by the Philippine Pediatric Society because we lacked a few requirements. Getting residency training accreditation was more difficult than JCIA. I needed to show you how determined I was at getting Asian Hospital accredited. I went home that day and cried my heart out, but I didn't want to show you my weak side. Of course I cry! I also bleed. The second try last August 2014 was nerve-wracking. There were questions that Drs. Mon Arcadio and Gener Becina would ask on the side, and I had no answers, but reassured them that I would be here always to make sure that we graduate our first trainees and make home grown pediatricians out of them.

I was in the middle of seeing patients, when Gener and Mon (and Madz) texted me last September 10 that the PPS Hospital Accreditation Board had granted Level 1 accreditation (3 years residency training program) to us. I sat down in the clinic and was teary-eyed looking at my cellphone in awe. My secretary came in and asked why I was crying. I told her the good news. Wiped my tears dry. And it was business as usual. Next patient please.

When I got home, I giddily announced to all the good news, my mom included. I took pride in my pediatric staff that we were able to show to all the other clinical departments that we would make the grade for residency program and that Pediatrics would be the first clinical department at Asian Hospital that would do this!

That night, I stayed up in my room making this post. It took awhile to compose it because I didn't really know what to write. But I knew that it was time.

To say goodbye.

But I'm finishing it today.

By saying thank you so much to all of you who have made my three years as chairman of the department a truly memorable one. Three years of getting to know more good people and making friends. Three years of making you part of my daily life. Three years of serving some of the very best pediatricians in the country. And yes, three years of believing in me and in our dreams and making these dreams a reality. I couldn't have been more blessed and thankful with a great, rowdy, crazy, happy bunch of doctors who made each day crazier and yet a blessing for me.

During the first exit interview with the PPS HAB, Gener told me that in all his years as part of the HAB, he has not seen so much love and support from a pediatric staff like the one at Asian Hospital. He told me that if he were to base accreditation for residency programs based on morale of the staff, we would be number 1.

And he's right. It takes people to make dreams come true.

Someone once said that a true leader is not someone who tells his people what to do and when to do it. A leader is a person who points in the direction for his people.

Thank you for giving me the opportunity to lead you.

See you around my friends...

Buwis-it!

The Philippine Daily Inquirer ran a short and irritating article regarding the interview over Radyo Inquirer with BIR honcho Kim Henares.

Henares: ‘People are very demanding but do not want to pay taxes’ read the title of the article.

“Ito ang problema: maraming gustong ipagawa ang mamamayan sa gobyerno. So padagdag at padagdag ‘yan, ‘di naman ‘yan nababawasan. So yun ang sinasabi namin. Kunyari, kung walang hihingiin na gagawin ang gobyerno, puwede tayong magbawas [ng tax revenue collection targets]. Ang problema, hindi naman ganyan. Very demanding lahat ng tao. Demanding, pero ayaw naman nila magbayad ng buwis. Saan tayo pupunta niyan?” said Henares in an interview over Radyo Inquirer 990 AM.

[This is the problem: the people want many projects to be implemented by the government. The demands are increasing and will not let up. That is what we are saying. For instance, if projects being demanded from the government are lessened, we can lower [our tax collection targets]. The people are very demanding. They are demanding but they do not pay their taxes. Where will we go from there?]

After reading this short, idiotic piece of trash, I was wondering where this woman even has the temerity to go mouthing on-the-air regarding tax collection.

I agree with her that people are very demanding. We demand transparency from the government. She's forgetting that her bosses are currently embroiled in too much shit - the pork barrel anomalies, the controversial DAP, the ghost projects - not to mention the fact there's so much graft and corruption even within her own agency. If she had all her people undergo a lifestyle check, I am sure that there would be less than 10% of the current employees in the BIR that would pass.

I agree with her that people do not want to pay taxes. Especially the marginalized. Make the jeepney drivers, taxi drivers, kuliglig drivers, sari sari store owners, those selling newspapers and cigarettes on the road, and hell, yeah, those doing business online pay taxes. Run after them as well. After all, they're the ones benefitting from the money I worked so hard for so that I can have better roads that don't need to get blocked every time a public vehicle decides to let people on and off even in a zone that has the whole sign emblazooned all over the street saying "NO LOADING and UNLOADING here"! After all, they're the ones benefitting from the taxes I pay so that their children can go to school and yet the government cannot even pay the teachers enough or that some local government has ghost schools and ghost teachers (?!?!?!). After all, they're the ones benefitting from the taxes I pay so that the local government units can hopefully provide them better health services but get siphoned off to bidding with low quality cheap medicines that have no active ingredient at all.

I disagree, however, that all her agency is tasked to do is collect taxes and that she needs to fulfill that goal whether she exercises duress on the taxpayers or not. You cannot justify what you do if the other branches of government are out there splurging your hard earned money into projects profited by government officials. And there's too much graft and corruption involving peoples' money which are not even supposed to be pocketed by government officials. She needs to remember that the branches of government are a unit all together. You cannot justify what you believe is morally right to you when you are collecting for people who malverse the very funds you collect from our sweat and blood.

It's called co-habitating with the enemy. You cannot profess what is morally upright when the other branches you work for are mired in graft and corruption. In short, wala kang karapatan magyabang kung ang mga kasama mo ay magnanakaw. While she is to be applauded for her bravado stand against the tax evaders, I have yet to see the Supreme Court actually side with her in the decisions she and the BIR have made against the heavy weights of tax evasion. And I have yet to see her flex her bravado on colleagues of hers in government (from the baranggay servant to the traffic enforcer to the policeman on the street to the general who lives with the rich and famous...oh did I forget anybody?) on massive corruption and tax evasion issues among the ranks - let's face it, the people in government should ALL have their lifestyles checked!

There is really nothing much to pride the BIR in terms of how they collect the taxes from the people. To say they are efficient is an understatement. They have made things more complicated for a reason I cannot comprehend. The actions of the BIR are based on distrust with the taxpayers. I get that. I would have admired her more if she made it her mission to simplify tax collection. But I guess that's beyond her brain capacity and not within her pay grade to make things simple.

http://newsinfo.inquirer.net/631590/henares-people-are-very-demanding-but-do-not-want-to-pay-taxes

Senior "moments"

My mom turns 77 today.

She is one of those senior citizens who have outlived more of my friends and her friends as well.

This is my second blog about the woman I fondly call INANG.

The woman who has provided me my day-to-day fears and inspirations on approaching the "senior citizen" years.

She is the woman who not only has stood by all of us in the family as the beacon of good, of guidance, and yes, of both dependence and independence.

Unlike most mothers who have established a career in the corporate world for themselves, my mother was a stay-at-home professional. As both I and my sister grew up, she was our maid, our driver, our cook, our teacher, and yes, our friend. She was the one person who knew what we felt even before the world knew about it. In her own small world, she shared her dreams and despairs with us.

When my father became ill and had to stop working after his debilitating stroke, INANG took the cudgels of being his cook, his maid, his driver, his therapist and yes, stood by him till the end. There was no day I could remember that my mom multitasked in a world that was not fair. Even from miles away during my fellowship in the United States, she would tell me how my father was and how one day, she too could go and see Boston. I felt the love between my father and mother. Even in sickness and in pain, there was love.

Like all of us, my mom had dreams. Not the grand ones where she would want to own a Prada or an LV. Hers were simple ones - of life well traveled, of life well lived, of a roof over our heads, of hot meals on the table, of the simple world of living life to the fullest and without regrets.

When my father passed away, she cried each night. I thought that his passing was a quick one. There was no suffering nor pain. During the wake, she would just stare at the coffin, wondering what life would be without him. She told me of stories of my dad's plans for both of them when they would grow old and it would just be the two of them. Then, she lost the only person who she thought she would share her life with in her old age. And all the dreams just crumbled.

And I was left to decide on how life would be with just me and INANG.

In the 20 years since my father died, it was just me and INANG.

I made it a point to make sure that Tuesdays with Nanay would be the story of her life. I don't work on Tuesdays just to be with my mom. Of course, it was less income, but eventually I discovered that not all the earnings of the day would compensate those precious 'moments' with mom. There was little I could repay her for raising me and supporting my dreams, when she gave up hers just to raise me and my sister.

Today, together with all the technological advancements, INANG still drives, is active in Facebook (and no, she does not Tweet...but I figure that someday Bob will also teach her how), still cooks, enjoys malling, plays Candy Crush & Bejeweled, enjoys making loombands, has a smartphone and yes, walks the dogs.

I make it a point that special occasions would be time out with my small family. My little way of reminding myself that what we give in life comes back to us the way we give. A gentle reminder that all things in this world will eventually pass but we can never relive the past. It's only TODAY that will make a difference in our lives and the lives of people we touch.

As we celebrate 77 years of INANG's life, I now know that those "moments" we spend with our parents are the most priceless ones they treasure. It's also the most important event in their lives as they travel the lonely road of their "senior" years.

Today, it's her time to SHINE!

I write with pride about a mother who has given everything unselfishly and forgiven and loved unconditionally so that we understand the kind of parents who raise us.

A life well lived is not one of material possessions, but one that is shared by the heart.

Happy birthday INANG!

I love you....I always will...

Saturdays

Almost every Saturday, Leny, Rose, Marivi and I would have breakfast before we start our day at the UST Hospital. It would be an hour or so of coffee, some food and a lot of story swapping. It's a ritual we have gotten accustomed to for the 6 years since I retired from teaching at the medical school. Like giddy girls who meet up for the usual chatter, breakfast on Saturdays is something I look forward to.

Today we had our banter at Jollibee along the corner of P. Noval and Lacson. We were missing Marivi who is attending a dermatology meeting in Idaho. While we were half way through breakfast, 3 children caught our attention. The eldest was girl of around 9 who had in tow, 2 boys around 5 and 3 years old. They brought up a tray - one piece of Yum Burger, one small cup of ice cream and a glass of water to share. Yup! They were street urchins who probably had collected enough from their begging so that they too, could have a decent meal.

A decent meal? What they had on their plates was even being share by three hungry children! The youngest of them had no slippers and their clothes were ragged and torn. They not only needed food, but a good bath as well.

They caught our attention and Leny was telling Rose and I that we should get them something decent to eat. I jokingly told her that if they develop diarrhea or abdominal pain from the food we give, their parents would run after us. Yet something kept tugging at our hearts. Watching the three of them share the little food they had would make one appreciate what we have because there are others who have even less.

Rose and I asked Rince (the crewmember's name at Jollibee) to get the kids one spaghetti meal each! After giving Rince some money, he dashed off with much enthusiasm and came up serving the three children a whole meal for each. I've got to give it to Rince because he treated them like VIP, serving them the hot plates, arranging the sodas for them properly, giving them utensils and paper napkins. The three children stared at the food and began enjoying the spoils in front of them.

What was amazing was that the kindness we shared was shared by those who saw us. One man bought the children some fries. Another man came up with more ice cream and sat down and talked to them.

While they were still enjoying their meal, Leny, Rose and I decided to go back to the hospital to work.

No, we never took a selfie with the kids. I didn't think it was appropriate. I just wanted to share the story.

No, the children never said thank you. Their hunger and happiness on their faces was all the thank you we needed. Besides, we did it not because we wanted compliments in return.

No, we didn't get a chance to talk to them. They were busy with breakfast.

And yes, to us it was an ordinary Saturday. To the children, it may have been a very special Saturday. The ritual gathering among friends was made special by three children who tugged our hearts and taught us that sharing takes on a different meaning and perspective when you know somehow, even in a fleeting moment, you've made a better day for someone.


"The little things we give to others will come back as blessings in some other day..
To those who share their unselfish hearts never get tired of doing little things for others because sometimes those little things occupy the biggest part of their hearts."

#europevacation2014 - the highs and lows (final chapter)

4. NICE, FRANCE

Located in the south east coast of France on the Mediterranean Sea is the second largest city in the Provence-Alpes-Cote d'Azur (after Marseille.

Nice was selected as our residential destination on this part of the final legs of our vacation for the location. It is a 30-40 minutes train ride to other two destinations - Monaco and Cannes.

After getting new train tickets from Milan to Nice (via Ventimiglia), we arrived almost 10PM at the Hyatt Regency Nice Palais de la Mediterranee (only 3 blocks but 20 euros) from the train station in Nice.

The front desk and concierge of this hotel was wonderful and because the restaurants were closed already, and they fully understood my unfortunate incident in Milan, the hotel manager called the bar restaurant to serve us dinner at the bar (instead of having to have a cluttered room service). Tired, hungry and yes, depressed, the Hyatt Regency Nice was a notch in service and style. It would be home for the next 4 days and 3 nights.

Transportation in Nice is perfect. The train station is called Nice-Ville and the Cote d'Azur airport is the second busiest airport in France. While Nice is actually compact - you get the best of the French Riviera in Nice and in Cannes.

5. CANNES, FRANCE

Lucky stars shine on you when you've prepared for a vacation but didn't know that surprises awaited you. We were there in time for the Annual Cannes Film Festival. After a late breakfast, we took the short train ride to Cannes. (Remember to get the direct train rides. It takes you there in a shorter period of time sans the multiple stops in other towns.)

In Cannes, there were just rows and rows of high-end luxury shops by the beach. From the train station to the beach area, one will pass rows and rows of restaurants where both tourists and the locals mingle for late (and very late) lunch. And the boats, yachts and ships that were parked on the seaport were screaming signs of wealth and opulence. The lifestyle of truly - the rich and famous.

6. MONACO

The Principality of Monaco is bordered by France and the Mediterranean Sea. It is the second smallest country in the world with an area of around 2 km and a population of less than 40,000 people. It is governed by a constitutional monarch and Prince Albert II (belonging to the House of Grimaldi that have ruled since the 1200s) is the current head.

Monaco saw its rise in economics and fame during the reign of Prince Rainier III who married Hollywood star Grace Kelly. The latter was loved by the people of Monaco and the adulated by the world as Princess Grace!

As in the previous leg of our vacation, we were lucky to see the opening of the annual F1 race in this affluent principality.

It's a very small country and don't forget to visit the residential palace of the Grimaldis, the church where the royals are buried, the Casino Royale (from the Bond movie) and the beautiful gardens and museum of cars of the Princes.

7. BARCELONA, SPAIN

The final leg of the vacation (and yeah - we didn't think we would say this, but this was getting too long, too weary and too tiring to enjoy). We took a short plane ride from the Cote d'Azur Airport and landed at El Prat Airport in Barcelona, Spain.

Of all the hotels during our stay, the Ohla Hotel in Barcelona was by far the best! It was the swankiest and had a divine one star Michelin restaurant in its premises. The food was excellent and breakfast was simple and very good! It wasn't one of those buffet spreads that would make you literally puke at the abundance! The hotel serve you Cava Champagne on arrival (with cold towels). It is located right in the middle of the 5 km shopping district! The subway is right in front (to the left) of the hotel and the stores are just miles and miles of walking at our back. What's great about the hotel is the fact that it smells sooooooo good, which is a nice thing about boutique hotels. [Just a note: If you're a bit shy, and you're just sharing the room with a friend, I suggest you get another hotel. The shower in the room is all glass and is found right in the middle of the room!]

Barcelona is Gaudi land. There will always be a piece of Gaudi that you will need to explore and explore we did. For the 3 days stay, we decided to do a hop-on-hop-off tour and enjoy the Tapas and exquisite Spanish Cuisine!

Emirates provide transfers to and from the airport to the hotel of your destination if you're flying on Business Class. It's an added benefit to beginning and ending a wonderful vacation.

It's finally back to reality and back to working to earn enough for next year's vacation!